Venous Access
Curtis A. Lewis, MD, Timothy E. Allen, MD, Dana R. Burke, MD, John F. Cardella, MD, Steven J. Citron, MD,
Patricia E. Cole, MD, PhD, Alain T. Drooz, MD, Elizabeth A. Drucker, MD, JD, Ziv J. Haskal, MD,
Louis G. Martin, MD, A. Van Moore, MD, Calvin D. Neithamer, MD, Steven B. Oglevie, MD,
Kenneth S. Rholl, MD, Anne C. Roberts, MD, David Sacks, MD, Orestes Sanchez, MD, Anthony Venbrux, MD,
Curtis W. Bakal, MD, MPH, for the Society of Interventional Radiology Standards of Practice Committee
J Vasc Interv Radiol 2003;14:S231–S235CENTRAL venous access is an integral
component in the care of patients with
malignant, infectious, and chronic
dis-eases. Image-guided placement of
cen-tral venous access catheters has been
proven to be very safe and effective in
providing access to the central venous
circulation (1–21). Image-guided
per-cutaneous placement of venous
cathe-ters and ports has become the method
of choice in many institutions because
it has reduced morbidity and
mortal-ity and has helped to reduce costs and
length of stay in the hospital (5,7,8,10 –
13,16 –25).
Participation by the radiologist in
patient follow-up is an integral part of
central venous access and will increase
the success rate of the procedure.
Close follow-up, with monitoring and
management of the central venous
ac-cess device, is appropriate for the
ra-diologist.
These guidelines are written to be
used in quality improvement programs
to assess percutaneously placed central
venous access devices. The most
impor-tant processes of care are (a) patient
se-lection, (b) procedure performance, and
(c) patient monitoring. The outcome
measures or indicators for these
pro-cesses are indications, success rates, and
complication rates. Outcome measures
are assigned threshold levels.
DEFINITIONS
Image-guided percutaneous central
venous access is defined as the
place-ment of a catheter with its tip in the
caval atrial region utilizing the
assis-tance of real-time imaging. The most
commonly used imaging techniques
during placement include fluoroscopy
and ultrasonography.
Tunneled catheters are defined as
catheters that travel through a
subcu-taneous tract prior to exiting the body
through a small incision in the skin.
Implanted ports are similar to
tun-neled catheters. However, they do not
exit the skin, but terminate with a
de-vice buried in the subcutaneous
tis-sues. The catheter exit or implanted
port site can be located in several
dif-ferent locations but is usually placed
over the torso/neck or peripherally.
However, other alternative access
routes have been described (3,9,10,
15,22,26).
Successful placement is defined as
follows: introduction of a catheter into
the venous system with the tip in the
desired location and the catheter
func-tions for its intended use (eg, can be
used to deliver medications or for
di-alysis). Functional success is the most
important component of this
defini-tion.
While practicing physicians should
strive to achieve perfect outcomes (eg,
100% success; 0% complications), in
practice all physicians will fall short of
this ideal to a variable extent.
There-fore, indicator thresholds may be used
to assess the efficacy of ongoing
qual-ity improvement programs. For the
purpose of these guidelines, a
thresh-old is a specific level of an indicator
that should prompt a review.
“Proce-dure thresholds” or “overall
thresh-olds” reference a group of indicators
for a procedure (eg, major
complica-tions for the placement of central
ve-nous access devices). Individual
com-plications may also be associated with
complication-specific thresholds. When
measures such as indications or
suc-cess rates fall below a (minimum)
threshold, or when complication rates
exceed a (maximum) threshold, a
re-view should be performed to determine
causes and to implement changes, if
necessary. Thresholds may vary from
those listed here; for example, patient
referral patterns and selection factors
may dictate a different threshold value
for a particular indicator at a
particu-lar institution. Therefore, setting
uni-versal thresholds is very difficult and
each department is urged to alter the
thresholds as needed to higher or
lower values, to meet its own quality
improvement program needs.
Complications can be stratified on
the basis of outcome. Major
complica-tions result in admission to a hospital
for therapy (for outpatient
proce-dures), an unplanned increase in the
level of care, prolonged
hospitaliza-tion, permanent adverse sequelae, or
death.
Minor complications result in no
se-This article first appeared in J Vasc Interv Radiol 1997; 8:475– 479.
Address correspondence tothe SIR, 10201 Lee Hwy, Suite 500, Fairfax, VA 22030.
© SIR, 2003
DOI: 10.1097/01.RVI.0000094590.83406.9e
quelae; they may require nominal
ther-apy or a short hospital stay for
observa-tion (generally overnight) (Appendix
A). The complication rates and
thresh-olds below refer to major complications.
INDICATIONS FOR CENTRAL
VENOUS ACCESS
Indications for central venous
ac-cess are listed in Table 1. The
thresh-old for these indications is 95%. When
fewer than 95% of procedures are for
these indications, the department will
review the process of patient selection.
The decision to place a central
ve-nous access device should be made
after considering the risks and benefits
to each patient. Coagulopathy and
sepsis may be relative
contraindica-tions to immediate implantation of
long-term central venous access
de-vices. Appropriate effort should be
made to correct or improve a patient’s
coagulopathy prior to placement of a
central venous catheter. Other factors
that may also increase complications
include venous stenosis, acute
throm-bosis, and local skin infection at the
insertion site. In patients in whom
these findings or abnormalities cannot
be corrected, the procedure may still
be indicated if the risk/benefit ratio is
lower than the alternative methods of
diagnosis or treatment.
SUCCESS RATES OF CENTRAL
VENOUS ACCESS
Success rates for central venous
ac-cess are listed in Table 2, along with
recommended threshold values.
COMPLICATIONS OF
CENTRAL VENOUS ACCESS
Complications are defined as early
(occurring within 30 days of
place-ment) or late (occurring after 30 days).
Early complications can be subdivided
into procedurally related, defined as
those that occur at the time or within
24 hours of the intervention, and those
occurring beyond that period.
Compli-cations that occur at the time of the
procedure usually consist of injury to
the surrounding vital structures or
malpositioning of the catheter tip. The
incidence of early complications is
lower with image-guided techniques
when compared to blind or external
landmark techniques (7,27,31,34,38,43).
Complications (major and minor)
occur in approximately 7% of patients
when image guidance is used (7,11,
14,18,20,31,37,39). Published
complica-tion rates and suggested thresholds
are listed in Table 3.
Published rates for individual types
of complications are highly dependent
on patient selection and are based on
series comprising several hundred
pa-Table 1Indications for Central Venous Access Therapeutic Indications
Administration of chemotherapy Administration of total parenteral
nutrition
Administration of blood products Administration of intravenous
medications
Intravenous fluid administration Performance of plasmapheresis Performance of hemodialysis
Diagnostic Indications
To establish or confirm a diagnosis To establish a prognosis
To monitor response to treatment For repeated blood sampling
Table 2 Success Rates Reported Rates (%) Threshold (%) Internal jugular approach (4,22,27–35) 96 95 Subclavian vein approach
Catheter (6,8,11,14,16,17,19,22,23,28,31–33,36–44) 95 90 Infusion port (16,18,22,23,45) 95 90 Peripherally inserted central catheters (PICC)
(1,7,20,22,23,25,46–51)
96 90 Peripherally implanted ports
(2,5,10,12,13,16,21,23,24,48,52–57)
96 90 Translumbar approach (9,15,26) 96 90 Note.—Success rates and thresholds listed are for the adult population and could be expected to be lower in a pediatric population.
Table 3
Complication Rates and Suggested Thresholds for Central Venous Access
Specific Major Complications for Image-guided Central Venous Access
Rate (%)
Suggested Threshold
(%)
Subclavian and jugular approaches
Pneumothorax 1–2 3 Hemothorax 1 2 Hematoma 1 2 Perforation 0.5–1 2 Air embolism 1 2 Wound dehiscence 1 2 Procedure-induced sepsis 1 2 Thrombosis* 4 8
Peripheral placement PICC and peripheral ports
tients, which is a volume larger than
most
individual
practitioners
are
likely to treat. It is also recognized that
a single complication can cause a rate
to cross above a complication-specific
threshold when the complication
oc-curs in a small volume of patients (eg,
early in a quality improvement
pro-gram). In this situation, the overall
procedure threshold is more
appropri-ate for use in a quality improvement
program.
The overall procedure threshold for
major complications resulting from
image-guided central venous access
including the subclavian, jugular and
peripheral approaches is 3%.
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